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Version 1.0
Guideline No. 14
Table of Contents
Key Recommendations ................................................................................... 3
1. Purpose and Scope ..................................................................................... 5
2. Background and Introduction....................................................................... 5
3. Methodology.............................................................................................. 5
4. Clinical Guidelines ...................................................................................... 6
4.1 Diagnosis of multiple pregnancy ................................................................. 6
4.2 Delivery of Antenatal and Perinatal Care ..................................................... 6
4.3 Preterm Delivery ...................................................................................... 6
4.4 Indications for referral to a tertiary-level Fetal Medicine Unit ......................... 7
4.5 Ultrasound surveillance ............................................................................. 8
4.6 Twin-twin transfusion syndrome................................................................. 9
4.7 Timing of Delivery .................................................................................... 9
4.8 Mode of Delivery .................................................................................... 10
5. References .............................................................................................. 11
6. Implementation Strategy .......................................................................... 14
7. Key Performance Indicators....................................................................... 14
8. Qualifying Statement ................................................................................ 14
Key Recommendations
1. Where multiple gestation is identified on ultrasound examination, chorionicity
should be assigned at the earliest opportunity. This is best achieved before 14
weeks gestation.
2. A record should be retained of the ultrasound image that supports assignment of
chorionicity and a second opinion should be sought if there is uncertainty.
3. If chorionicity cannot be determined, monochorionicity should be assumed until
proven otherwise, and a strategy of prenatal surveillance that includes screening
for twin-twin transfusion syndrome should be adopted accordingly.
4. Prenatal and perinatal care should be hospital-based for all multiple gestations,
coordinated by an obstetrician experienced in the management of multiple
gestation.
4.1.
4.2.
4.3.
4.4.
4.5.
4.6.
4.7.
3. Methodology
Medline, EMBASE and Cochrane Database of Systematic Reviews were searched
using terms relating to multiple gestation, twin pregnancy, prenatal care, labour
and delivery complications, higher order multiple gestation. Searches were limited
to humans and restricted to the titles of English language articles published
between 1982 and 2012.
Relevant meta-analyses, systematic reviews, intervention and observational studies
were reviewed. Particularly pertinent in the Irish setting are the data gleaned from
the large prospective ESPRiT Study (Evaluation of Sonographic Predictors of
Restricted growth In Twins) conducted between 2007 and 2009, which offers
contemporaneous twin data from eight tertiary referral obstetric units in Ireland.
Guidelines reviewed included NICE guideline on Multiple Pregnancy (September
2011), Royal College of Obstetricians and Gynaecologists guideline on Management
of Monochorionic Twin Pregnancy (Guideline No 51; December 2008), American
College of Obstetricians and Gynecologists Practice Bulletin No 56: Multiple
Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy (October
2004) and Royal Australian and New Zealand College of Obstetricians and
Gynaecologists guideline on Management of Monochorionic Twin Pregnancy (C-Obs
42; March 2011).
The principal guideline developer was Dr Fionnuala Breathnach, Consultant
Obstetrician/ Gynaecologist at the Rotunda Hospital and Senior Lecturer in Maternal
Fetal Medicine, Royal College of Surgeons in Ireland. The guideline was peerreviewed by Dr Liz Dunn (Wexford), Professor Sean Daly (Coombe), Dr Michael
Gannon (Mullingar), the Institutes Clinical Advisory Group.
4. Clinical Guidelines
4.1 Diagnosis of multiple pregnancy
Perinatal outcome in multiple pregnancy is largely driven by chorionicity, the
accurate assignment of which is therefore of critical importance. Where multiple
pregnancy is identified on ultrasound examination, the chorionicity and amnionicity
of the pregnancy should be determined at the earliest opportunity. This is best
achieved before 14 weeks gestational age, by determining the number of
placental masses, the lambda or T-sign and thickness of the intertwin membrane.
If in doubt, a second opinion should be sought.
This differentiation becomes more difficult later in gestation and, in the setting of
concordant fetal gender, it may not be possible to confidently assign chorionicity.
Under such circumstances, the pregnancy should be described as of undetermined
chorionicity and monochorionicity should be assumed until proven otherwise.
When chorionicity is assigned, a photographic record of the ultrasound
image that supports that assignment should be kept in the womans
record.
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5. References
Adam C, Allen AC, Baskett TF. Twin delivery: influence of the presentation and
method of delivery on the second twin. Am J Obstet Gynecol 1991;165:23-7.
American College of Obstetricians and Gynecologists
Multiple Gestation: Complicated Twin, Triplet, and High-order Multifetal Pregnancy.
Practice Bulletin Number 56, October 2004
Armson BA, OConnell C, Persad V, Joseph KS, Young DC, Baskett TF. Determinants
of perinatal mortality and serious perinatal morbidity in the second twin. Obstet
Gynecol 2006;108:556-64.
Barigye O, Pasquini L, Galea P et al. High risk of unexpected late fetal death in
monochorionic twins despite intensive ultrasound surveillance: a cohort study. PLoS
Med 2005;2:e 172.
Berghella V, Odibo A, To M, Rust O, Althuisius S. Cerclage for short cervix on
ultrasound meta-analysis of trials using individual patient-level data. Obstet
Gynecol 2005;106:181-9.
Breathnach FM, McAuliffe FM, Geary M, Daly S, Higgins JR, Dornan J et al.
Definition of intertwine birth weight discordance. Obstet Gynecol 2011; 118(1) 94103.
Breathnach FM, McAuliffe FM, Geary M, Daly S, Higgins JR, Dornan J et al. Optimum
timing for planned delivery of uncomplicated monochorionic and dichorionic twin
pregnancies. Obstet Gynecol 2012;119(1):50-9.
Combs CA, Garite T, Maurel K, Das A, Porto M. 17-hydroxyprogesterone caproate
for twin pregnancy: a double-blind, randomized clinical trial. Am J Obstet Gynecol
2011 Mar;204(3):221.e1-8.
Crowther CA. Cesarean delivery for the second twin. Cochrane Database Syst Rev
2000;CD000047.
Crowther CA, Hans S. Hospitalisation and bed rest for multiple pregnancy. Cochrane
Database Syst Rev 2010 Jul 7;(7):CD000110.
Donovan EF, Ehrenkranz RA, Shankaran S, Stevenson DK, Wright LL, Younes N et
al. Outcomes of very low birth weight twins cared for in the National Institute of
Child Health and Human Neonatal Development Neonatal Research Network,
January 1993 through December 1994. Am J Obstet Gynecol 1998;179;742-749.
Dor J, Shalev J, Mashiach S, et al. Elective cervical suture of twin pregnancies
diagnosed ultrasonically in the first trimester following induced ovulation. Gynecol
Obstet Invest 1982;13:55-60.
Durnwald CP, Momirova V, Peaceman AM, Scisione A, Rouse DJ, Caritis SN et al for
NICHD and MFMU Network. Second trimester cervical length and risk of preterm
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6. Implementation Strategy
Distribution of guideline to all members of the Institute and to all maternity
units.
Implementation through HSE Obstetrics and Gynaecology programme local
implementation boards.
Distribution to other interested parties and professional bodies.
8. Qualifying Statement
These guidelines have been prepared to promote and facilitate standardisation and
consistency of practice, using a multidisciplinary approach. Clinical material offered
in this guideline does not replace or remove clinical judgement or the professional
care and duty necessary for each pregnant woman. Clinical care carried out in
accordance with this guideline should be provided within the context of locally
available resources and expertise.
This Guideline does not address all elements of standard practice and assumes that
individual clinicians are responsible for:
Discussing care with women in an environment that is appropriate and which
enables respectful confidential discussion.
Advising women of their choices and ensure informed consent is obtained.
Meeting all legislative requirements and maintaining standards of professional
conduct.
Applying standard precautions and additional precautions, as necessary, when
delivering care.
Documenting all care in accordance with local and mandatory requirements.
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